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Book Reviews   |    
What's Behind the Symptom? On Psychiatric Observation and Anthropological Understanding
Reviewed by Mohan Chawla, M.D., M.R.C.Psych.
Psychiatric Services 2001; doi: 10.1176/appi.ps.52.9.1265
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by Angel Martínez-Hernáez; translated by Susan M. DiGiacomo and John Bates; Amsterdam, Harwood Academic Publishers, 2000, 277 pages, $54

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The collaboration of anthropological understanding and psychiatry in contemporary psychiatric literature has been gradually developing in recent years. What's Behind the Symptom? is an excellent contribution to this project, not least because the author's background straddles both disciplines: Angel Martínez-Hernáez has a Ph.D. in social anthropology and a master's degree in social psychiatry as well as training in Freudian psychoanalysis.

His vision in this book, he says, is for mental health professionals to conceptualize psychological symptoms "as an open process, a communicative act, the result of creative interplay of values and discourses, everyday experience, local knowledge, and forms of oppression." He explains clearly how symptoms can be assigned to the context of a particular psychopathology just as they can be assigned to a particular cultural framework, and he elaborates how a symptom can equally be understood as a natural consequence of psychophysiological processes or as a message, text, or discourse. He uses the simple analogy of the difference between a twitch of the eye and a wink; he suggests that, in some ways, contemporary psychiatry treats winks as twitches.

Martínez-Hernáez challenges the applicability of Mishler's three silent assumptions of biomedical knowledge in psychiatry—disease as deviation from normal biological functioning, the doctrine of specific etiology, and the supposed neutrality of biomedicine. From there, he elucidates the principle that no criteria of normality can exist independently of the sociocultural characteristics of a population. He contrasts "voodoo death" as an illustration of the power of social influences in a negative way and the "placebo effect" in a positive way.

His comparison of neo-Kraepelian thinking as viewing symptoms as a manifestation of biologically based processes and Freudian thinking as viewing symptoms as a part of a structure appears somewhat simplistic. His assertion that we should look for latent meaning when addressing psychiatric problems can be of immense help in working with long-term problems, but this approach might face some difficult practical dilemmas in acute psychiatric practice.

The author's analysis of the perception that mental disorders have to do with being rather than having—for example, "J is a schizophrenic" versus "J suffers from coronary heart disease" —explains in a very simple manner the difficulties we have as a result of thinking in terms of a mind-body duality, which is deeply rooted in Cartesian doctrine. His challenge on the aseptic and objective image of biomedical psychiatry is well explained, in simple and jargon-free language that would appeal to all mental health professionals seeking a deeper understanding of psychiatric problems.

He also explains nicely how a strict adherence to the biomedical view of psychiatry serves to convert the story of an individual into an inventory of facts reshaped in terms of diagnostic criteria, as though clinical procedure were being converted into investigation. His criticism of "scientism" must be understood with some caution, however, as it could potentially be perceived as a departure from a scientific approach—an implication I am sure is unintended.

I would recommend What's Behind the Symptom? to all readers who are interested in a deeper or an alternative understanding of mental health issues; a careful reading of this book will enrich their understanding of an evolving field.

Dr. Chawla is a consultant psychiatrist and clinical tutor at Kettering General Hospital in Kettering, England.

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